Transcript Slide 1
Prosecutorial Administrative Actions
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Successful criminal prosecution
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Court-ordered restitution
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Sanctions by professional certification boards
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Indictments
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Warrants
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Arrests
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1 000 900 800 300 200 100 0 700 600 500 400
474 2007
Medical Fraud
804 562 909 2008
Medical Related PAAs
2009 2010
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2010 Medical Fraud Trends
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Questionable Claim Referrals Indicate:
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40% of the total Casualty Referral Reasons are allegations of wrongdoing by the medical provider
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Duplicate Billing
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Excessive Treatment
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Provider/ Facility Improperly Licensed
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Billing for Services Not Rendered
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Solicitation
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Inflated Billing
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Unbundling/ Upcoding
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Aggregated Medical Database
Overview:
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Top data analytic priority identified in the Integrated Business Plan
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Goal is to aggregate and analyze medical billing data to identify suspect providers
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BOG approved NICB proposal to engage Health Care Insight in developing the AMD
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Aggregated Medical Database
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Enhance NICB’s ability to combat medical provider fraud - Increase access to industry data that is non-existent today - Identify medical providers perpetrating fraud across P&C industry - Prioritize investigations of suspect providers - Publish MedAWARE SM Alerts specific to findings to participating members - Increase prosecution of fraudulent medical providers
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Aggregated Medical Database
Step 1 •
Memorandum of Understanding
• Twenty carriers signed MOU Step 2 •
Carrier Data On-Boarding
• Multiple carriers in various states of readiness • Auto and Workers’ Compensation data represented Step 3 •
Analysis and Analytics Applied
• Target to focus on applicable edits & conditions • Development of customized conditions Step 4 •
Clinical Review
• Reduce false positives • ”The Human Touch” Step 5 • •
Results
• Provides referrals for NICB analysis
Med
AWARE SM Alerts to participating carriers • 1 st Alerts were posted on April 19, 2011 6
MedAWARE
SM
Alerts
MedAWARE SM Alerts are posted on the Members-Only Web Site and are viewable only to participating members.
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Commercial Fraud
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Specialized Equipment
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Cargo Theft
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Slip and Fall Rings
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